Interferons in MPNs

Perspectives on The Early Interferon Concept

Combination Therapy with Ruxolitinib and Interferon

Hans Hasselbalch

Department of Hematology

Roskilde Hospital

University of Copenhagen

Denmark

Bologna

May 9, 2016

Interferon Alpha2 in MPNs

History of Interferons

Biology and Mechanisms of Action

The Novel Concept of Chronic Inflammation in MPNs

Early Intervention Concept

Minimal Residual Disease

Interferon Resistance and Intolerability

Perspectives – Combination Therapy with Ruxolitinib

Honorary President

Sante Tura

• Interferon-Alpha2 in Chronic Myelogenous Leukemia

• Interferon-Alpha2 in Essential Thrombocythemia and Polycythemia Vera

• Interferon-Alpha2 in Hairy Cell Leukemia

• Interferon-Alpha2 in Malignant Lymphoma

• Interferon-Alpha2 in Chronic Lymphocytic Leukemia

• Interferon-Alpha2 in Mycosis Fungoides

• Interferon-Alpha2 in Cutaneous T-Cell Lymphoma

• Interferon-Alpha2 in BCR-ABL Positive Acute Lymphoblastic Leukemia

• Interferon-Alpha2 in Multiple Myeloma

• Interferon-Alpha2 in Immune Thrombocytopenic Purpura

66 Papers from 1987-2004

Gugliotta L, Macchi S, Catani L, Chetti L, Mattioli Belmonte M, Guarini A, Criscuolo D,Tura S.

Recombinant alpha-2a interferon (alpha-IFN) in the treatment of essential thrombocythaemia..

Haematologica. 1987 May-Jun;72(3):277-9

”New Drugs in Hematology”

INTERFERON

1957 : IFN is the first cytokine discovered ( Isaacs & Lindemann )

1978 : purification,analyses and characterization

1980 : Cloning of recombinant human IFN-alpha and beta

1983 : First report of efficacy in CML

1985 : First report of efficacy in ET Linkesch W & Gisslinger H

1986 : FDA approval for treatment of HCL

1987 : First report of efficacy in MF Parmeggianni L et al

1988 : First report of efficacy in PV Silver RT

2016 : No approval for treatment of MPNs

Burning Questions

Why interferon ?

When Interferon ?

Why Interferon-Alfa ?

30 Years of Clinical Experience

Single Arm Studies

> 1000 Patients

Safe

Efficaceous

When Interferon-Alfa ?

From The Time of Diagnosis

Tumor Burden at The Minimum

Most Efficaceous

Interferons

in Ph-Negative MPNs

Interferon alpha-2b ( Introna/PegIntron)

Interferon alpha-2a (Pegasys)

AOP2014, a Novel Peg-Proline-Interferon Alpha-

2b

. Kiladjian JJ, Mesa RA, Hoffman R. Blood. 2011 ; 5;117(18):4706-15

Kiladjian, J.-J. et al. Blood 2006;108:2037-2040

Interferon-Alpha2 Significantly Reduces

The JAK2V617F-Allele Burden

Interferon Alfa Therapy in

CALR-Mutated Essential Thrombocythemia

Cassinat B. Verger E,Kiladjian JJ. New Eng J Med 2015; 188-189

Interferon Alpha2 in MPNs

History of Interferons

Biology and Mechanisms of Action

The Novel Concept of Chronic Inflammation in MPNs

Early Intervention Concept

Minimal Residual Disease

Interferon Resistance and Intolerability

Perspectives

Interferon-Alpha

Mechanisms of Action

Antiproliferative

Proapoptotic

Antiangiogenic

Immunoregulatory

Inhibition of telomerase

Interferon-Alpha

Immunoregulatory Activities

Stimulate the cytotoxic activity of T-cells, NK-cells, monocytes,

macrophages and DC

Enhanced expression of anti-apoptotic genes in T-lymphocytes

Increased expression of tumor-associated and HLA- antigens

?

IFN-alpha IFN-alpha

Stem Cell Wake Up Call

CALR

Hematopoietic Niches: A Therapeutic Target for IFN ?

IFN-alpha2 wakes up dormant stem cells , put them in cycle and mobilize them to be

targets for potent tumor killing IFN-alpha2 blocks the intramedullary release of cytokines from the bone marrow stroma

IFN-Alpha2

Interferon Alpha2 in MPNs

History of Interferons

Biology and Mechanisms of Action

The Novel Concept of Chronic Inflammation in MPNs

Early Intervention Concept

Minimal Residual Disease

Interferon Resistance and Intolerability

Perspectives

Tumor Burden and Comorbidity Burden in MPNs

PV Post PV MF ET

Comorbidity Burden

?

AML

Unknown

genetic

event JAK2 V617F, CALR

Chronic phase Accelerated phase

100%

Lympho-myeloid precursor

Stem cell

Chronic Inflammation ?

Chronic Inflammation ? Chronic Inflammation ?

MPNs

ET – PV - PMF

A Human Inflammation Model ?

A Human Cancer Model ?

Chronic Inflammation – Genomic Instability - Clonal Evolution ?

Oxidative Stress – ROS-Genomic Instability - Cancer

• JAK2V617F induces accumulation of ROS

• ROS induces DNA-damage in stem cells

• DNA-damages induce genomic instability

• Genomic instability induces mutations

Marty C, Lacout C, Droin N et al. A role for reactive oxygen species in

JAK2(V617F) myeloproliferative neoplasm progression. Leukemia. 2013 Apr 5.

Smoking is a Highly Potent Inflammation Stimulus

A simplistic model of hematopoietic stem cell niches

Lataillade JJ, Pierre-Louis O, Hasselbalch HC , Uzan G, Jasmin C, Martyré MC, Le Bousse-Kerdilès MC; French INSERM

and the European EUMNET Networks on Myelofibrosis. Does primary myelofibrosis involve a defective stem cell niche?

From concept to evidence. Blood. 2008 15;112(8):3026-35.

An even more simplistic model of hematopoietic stem cell niches

The chicks are flying prematurely (escaping) from the burning nest

The Inflamed Bone Marrow

Oxidative Stress – ROS Accumulation

Genomic Instability – Mutagenesis - Metastastis

Neutrophil Granules

MMM

• Mobilization

• Metastasis

• Myeloid Metaplasia

11-05-2016 31

The Inflamed Bone Marrow

Cytokine Storm

Bone Marrow Failure

TNF-Alpha

IL-6 ,IL-8

IL-11, HGF

TNF-Alpha

IL-6 ,IL-8

IL-11, HGF

Inflammation in The Bone Marrow

Inflammation in The Circulation

Circulating Leukocyte –Platelet Aggregates

Microcirculatory Disturbances

Myelofibrosis with huge splenomegaly

Anemia: bone marrow failure, hemodilution, pooling, sequestration,

hyperhemolysis, portal hypertension, bleeding

Hemodilution

Pooling

Sequstration

Hyperhemolysis

Portal Hypertension

Inflammation

Inflammation in The Spleen

Chronic Inflammation and Oxidative Stress

Clinical Implications ?

• Driver of clonal evolution , mutagenesis, subclone

formation and myelofibrotic /leukemic transformation

in MPNs ?

• Driver of development of premature atherosclerosis

and early ageing ?

• Driver of development of other inflammation-mediated

comorbidities , including second cancers ?

Chronic Inflammation and Oxidative Stress

Therapeutic Implications ?

• Induction of resistance /refractoriness to treatment ( eg.

more hydroxyurea needed to control (inflammation-

mediated ) leuko-and thrombocytosis ?)’

• Impairment of IFN-signalling ?

How to Quell the Fire ?

• Early intervention when the chance of quelling

the fire is the very best :

• STOP THE FUEL SUPPLY : Interferon-alpha

• ANTIINFLAMMATION : JAK1-2 inhibitor, statins ?

Two Different Scenarios

No Access IFN-alpha2 Access IFN-alpha2

• ”Do no harm”

• Risk stratification

• Normal blood counts

• Cytogenetic remission

• Molecular remission

• Normal bone marrow

• Minimal residual disease

• ”Do no harm”

• Risk Stratification

• Normal blood counts

• Cytogenetic remission

• Molecular remission

• Normal bone marrow

• Minimal residual disease

Two Different Scenarios

No Access IFN-alpha2 Access IFN-alpha2

• STOP HU

Sustained

• Complete HR

• Molecular remission

• Normal bone marrow

• Minimal residual disease

• STOP IFN

Sustained

• Complete HR

• Molecular remission

• Normal bone marrow

• Minimal residual disease

A subset of patients

Two Different Scenarios

No Access IFN-alpha2 Access IFN-alpha2

• HU (>10 yrs)

•

• Risk of

• Skin cancer ?

• MDS/AML ?

• Second cancer ?

• IFN-alpha2

•

• Risk of

• Skin cancer ?

• MDS/AML ?

• Second cancer ?

Rationales for Early Intervention with IFN-Alpha2

Major /Complete Molecular Remissions after Long-Term Treatment ( > 3

-5 years)

Sustained Molecular Remissions after Discontinuation of IFN-alpha2

Minimal Residual Disease

JAK2V617F ET : the Early Phase of PV in a Subset of Patients

“ET “ Early Phase of Myelofibrosis in a Subset of Patients

The JAK2V617F-mutation a thrombosis promoter

The Goal ?

„Minimal Residual Disease“

„Operational Cure „

Cure?

Sustained Molecular Response in Polycythemia Vera

Treated with Interferon Alfa-2b

Figure 1: Bone marrow histomorphology from patient 1 at a) time of diagnosis 1996 and b)

just prior to treatment with IFN alfa-2b. Both panels demonstrate classical PV features with

hyperplasia and clustering of morphological abnormal megakaryocytes. Panel c) shows the

morphologically normal bone marrow from August 2007 (after eight years of treatment with

IFN-alfa 2b) with total regression of PV features (Larsen T et al Ann Hematol 2008; 87:

847–850)

Impaired

Tumor Immune Surveillance

in MPNs ?

Chronic Inflammation ?

Immune Deregulation ?

Chronic Inflammation and Second Cancer in MPNs

Perspectives :

• Down-regulation of HLA-genes is a ”tumor-escape mechanism” by which tumor

cells escape the attack from potent immune cells e.g. cytotocic T cells and NK-cells )

• Interferon-alpha2 potently upregulate HLA-genes on tumor cells thereby rendering

them accessible for tumor killing by IFN-alpha2

• Early treatment with IFN to enhance tumor cell killing

Interferon Alpha2 in MPNs

History of Interferons

Biology and Mechanisms of Action

The Biological Continuum (ET-PV-MF)

The Novel Concept of Chronic Inflammation in MPNs

Early Intervention Concept

Minimal Residual Disease

Interferon Resistance and Intolerability

Perspectives

Interferon Resistance

Interferon Resistance

Buxhofer-Ausch V, Gisslinger H, Berg T, Gisslinger B, Kralovics R.

Acquired resistance to interferon alpha therapy associated with homozygous MPL-

W515L mutation and chromosome 20q deletion in primary myelofibrosis.

Eur J Haematol. 2009 Feb;82(2):161-3.

The Molecular Heterogeneity of MPN is Complex

Variability in Molecular Responses to IFN-alpha

• TET2 clones persist in some patients

• Additional clones may impair the response to IFN-alpha2

• High hematological and molecular responses (48 (90%)and 18 (35%) patients, respect.)

• Responses achieved independently of chromosomal aberrations

• Complete cytogenetic remissions in three patients

Them N er al . Am J Hematol 90; 288-294,2015

DALIAH

A Danish Study of Low-Dose Interferon-alpha2

versus Hydroxyurea in Ph-Negative

Myeloproliferative Cancer

A National Multicenter Study on The Efficacy, Toxicity and QoL

200 Patients Included

Data Analysis Ongoing

Use Low Dose :

Pegasys 45 ug x 1 sc/week

PegIntron 30 ug x 1 sc/week

10-20 % side effects

Toxicity – Side Effects - Autoimmunity

Response Patterns

• the subgroup of patients with severe side effects ( drop out) -

a better and more rapid reponse to IFN ?

• The subgroup of patients with autoimmunity during treatment

with IFN – a better and more rapid response to IFN ?

Combination Therapy

Interferon Alpha2 + JAK Inhibitor

in Polycythemia Vera and Myelofibrosis

Safety and Efficacy of Combination Therapy of

Interferon-Alpha2 + JAK1-2 Inhibitor in the

Philadelphia-Negative Chronic Myeloproliferative

Neoplasms

Preliminary Results from the Danish Combi-Trial - an

Open Label, Single Arm, Non-Randomized Multicenter

Phase II Study

Stine Ulrik Mikkelsen1, Lasse Kjær1, Vibe Skov1, Mads Emil Bjørn1, Christen

Lykkegaard Andersen2, Ole Weis Bjerrum2, Nana Brochmann1, Daniel El Fassi3,

Torben A Kruse4, Thomas Stauffer Larsen4, Torben Mourits-Andersen5, Claus

Henrik Nielsen2, Niels Pallisgaard1, Mads Thomassen4 and Hans Carl Hasselbalch1 1Roskilde University Hospital, Roskilde, Denmark; 2Rigshospitalet, University Hospital

of Copenhagen, Copenhagen, Denmark; 3Herlev University Hospital, Copenhagen,

Denmark; 4Odense University Hospital, Odense, Denmark; 5Sydvestjysk Hospital,

Esbjerg, Denmark

Conclusions

• Combination therapy with IFNa2 and ruxolitinib is

highly efficacious in patients with PV or

hyperproliferative MF

• Combination therapy was generally well tolerated without any unexpected toxicities

• The results of this interim analysis suggest that combination therapy with IFNa2 and ruxolitinib may be a promising new treatment option in MPN patients

MPNs and Inflammation

Targeting The Malignant Clone and Inflammation

Both IFNα and JAK2 inhibitors reduce the high levels of inflammatory cytokines that

may be responsible for disease initiation and progression; accordingly, there is a strong

rationale for a combination of the two substance classes

This combination may result in a mutual augmentation of effects, leading to an increased

efficacy compared with single-agent therapy.

Combination therapy might allow the use of lower doses of each agent

Ultimately, the question arises of whether this combination may exhibit a disease-

modifying or curative effect

The ability of IFNα to induce molecular responses and the role of inflammation in the

initiation and progression of MPNs undoubtedly make such a combination therapy one

of the most promising new strategies in the management of MPNs

Koschmieder S, Mughal TI, Hasselbalch HC et al. Myeloproliferative neoplasms and inflammation:

whether to target the malignant clone or the inflammatory process or both.

Leukemia. 2016 ; 30(5):1018-24.

T-Cell

T-Cell

T-Cell NK-Cells

Killing of

Tumor Cells

Enhanced

Tumor Immune Surveillance

Statins JAK2-Inhibitor

Interferon-Alpha

Oxidative Stress

JAK1-2 Inhibition + Statins

Quelling the Fire

The Inflamed Bone Marrow Statins and Anti-inflammation

• Inhibit leukocyte activation

• Inhibit platelet activation

• Inhibit release of pro-

inflammatory cytokines

(eg. IL-6, TNF-alfa)

Statins inhibit JAK2V617F-dependent cell growth

Statins enhance JAK2 inhibition

Combination Therapy

Interferon Alpha2 + Ruxolitinib + Statin

HGF: hepatocyte growth factor; IL: interleukin; TNF: tumour necrosis factor

Interferon Alpha2 in MPNs

History of Interferons

Biology and Mechanisms of Action

The Biological Continuum (ET-PV-MF)

The Novel Concept of Chronic Inflammation in MPNs

Early Intervention Concept

Minimal Residual Disease

Interferon Resistance and Intolerability

Perspectives

Chronic Inflammation – Premature Atherosclerosis – Cancer

The chicks are flying prematurely (escaping) from the burning nest

The Inflamed Bone Marrow

Myelofibrosis with huge splenomegaly

Anemia: bone marrow failure, hemodilution, pooling, sequestration,

hyperhemolysis, portal hypertension, bleeding

Hemodilution

Pooling

Sequstration

Hyperhemolysis

Portal Hypertension

Inflammation

AML-M5

The Ugly Duckling . A Fairy Tale by Hans Christian Andersen

The Interferon Story

The Ugly Duckling Becoming The Beautiful Swan

The Ugly Duckling . A Fairy Tale by Hans Christian Andersen

Combination Therapy Interferon-alpha2 + Ruxolitinib

The Beautiful Swan Becoming Even More Beautful ?

The Future Looks Bright

Thank you for

your attention